title: Engagement in a diabetes self-management website: usage patterns and generalizability of program use.
abstract: BACKGROUND
  Increased access to the Internet and the availability of efficacious eHealth interventions offer great promise for assisting adults with diabetes to change and maintain health behaviors. A key concern is whether levels of engagement in Internet programs are sufficient to promote and sustain behavior change.
  
  
  OBJECTIVE
  This paper used automated data from an ongoing Internet-based diabetes self-management intervention study to calculate various indices of website engagement. The multimedia website involved goal setting, action planning, and self-monitoring as well as offering features such as "Ask an Expert" to enhance healthy eating, physical activity, and medication adherence. We also investigated participant characteristics associated with website engagement and the relationship between website use and 4-month behavioral and health outcomes.
  
  
  METHODS
  We report on participants in a randomized controlled trial (RCT) who were randomized to receive (1) the website alone (n = 137) or (2) the website plus human support (n = 133) that included additional phone calls and group meetings. The website was available in English and Spanish and included features to enhance engagement and user experience. A number of engagement variables were calculated for each participant including number of log-ins, number of website components visited at least twice, number of days entering self-monitoring data, number of visits to the "Action Plan" section, and time on the website. Key outcomes included exercise, healthy eating, and medication adherence as well as body mass index (BMI) and biological variables related to cardiovascular disease risk.
  
  
  RESULTS
  Of the 270 intervention participants, the average age was 60, the average BMI was 34.9 kg/m², 130 (48%) were female, and 62 (23%) self-reported Latino ethnicity. The number of participant visits to the website over 4 months ranged from 1 to 119 (mean 28 visits, median 18). Usage decreased from 70% of participants visiting at least weekly during the first 6 weeks to 47% during weeks 7 to 16. There were no significant differences between website only and website plus support conditions on most of the engagement variables. In total, 75% of participants entered self-monitoring data at least once per week. Exercise action plan pages were visited more often than medication taking and healthy eating pages (mean of 4.3 visits vs 2.8 and 2.0 respectively, P < .001). Spearman nonparametric correlations indicated few significant associations between patient characteristics and summary website engagement variables, and key factors such as ethnicity, baseline computer use, age, health literacy, and education were not related to use. Partial correlations indicated that engagement, especially in self-monitoring, was most consistently related to improvement in healthy eating (r = .20, P = .04) and reduction of dietary fat (r = -.31, P = .001). There was also a significant correlation between self-monitoring and improvement in exercise (r = .20, P = .033) but not with medication taking.
  
  
  CONCLUSIONS
  Participants visited the website fairly often and used all of the theoretically important sections, but engagement decreased over 4 months. Usage rates and patterns were similar for a wide range of participants, which has encouraging implications for the potential reach of online interventions.
  
  
  BACKGROUND
  NCT00987285; http://clinicaltrials.gov/show/NCT00987285 (Archived by WebCite at http://www.webcitation.org/5vpe4RHTV).
authors.affiliation: Institute for Health Research, Kaiser Permanente, Denver, CO, USA. russg@re-aim.net
authors.forename: Russell E
authors.initials: RE
authors.lastname: Glasgow
authors.forename: Steven M
authors.initials: SM
authors.lastname: Christiansen
authors.forename: Deanna
authors.initials: D
authors.lastname: Kurz
authors.forename: Diane K
authors.initials: DK
authors.lastname: King
authors.forename: Tim
authors.initials: T
authors.lastname: Woolley
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Faber
authors.forename: Paul A
authors.initials: PA
authors.lastname: Estabrooks
authors.forename: Lisa
authors.initials: L
authors.lastname: Strycker
authors.forename: Deborah
authors.initials: D
authors.lastname: Toobert
authors.forename: Jennifer
authors.initials: J
authors.lastname: Dickman
mesh_terms: D015190:Blood Glucose Self-Monitoring; D015992:Body Mass Index; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology / Q000523:psychology*; D004032:Diet; D005260:Female; D015438:Health Behavior; D006801:Humans; D020407:Internet / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009043:Motor Activity; D012648:Self Care / Q000706:statistics & numerical data*; D012944:Social Support; D013997:Time Factors